How can pharmacists contribute to a more effective care of patients with hypertension or diabetes? Sofia Österberg

Degree Thesis in Pharmacy 15 ECTS Bachelor’s Level Report passed: Spring 2015 Supervisor: Helena Holmgren Examiner: Jerker Fick

Abstract Introduction: Pharmacy services that include counseling of patients have been shown to be effective in improving disease states. Such consultative services can either take place face-to-face or the pharmacist can be working remotely through telepharmacy. People living in the rural parts of Sweden have a relative high mortality in myocardial infarction and diabetes. With regard to this fact, this study focus on how consultative pharmacy services can improve the health of patients with hypertension – which have an elevated risk of suffering from myocardial infarction – and diabetics. Objective: The questions addressed are: How can patient oriented consultative telepharmacy services in the primary care contribute to better outcomes for patients with hypertension? How can patient oriented consultative pharmacy services in the primary care or at pharmacies be used to improve the outcomes for diabetes patients? Method: A literature study was undertaken using PubMed to find publications that evaluated pharmacy services that included counseling of patients with hypertension or diabetes. The searches were made between March 25 and April 30, 2015. Results: Two out of three studies that analyzed telepharmacy services for hypertension patients showed a significant decrease in blood pressure for the patients receiving pharmacist interventions. Out of the 10 diabetes studies identified, 9 showed positive results with either improved blood glucose values or in reaching the blood glucose goal. Discussion: Although the studies analyzed have some limitations, e.g. low participant number and lack of control groups, they are encouraging regarding extending the pharmacists role in helping patients managing their diseases by providing consultative services. The longevity of the positive effects needs to be analyzed further. Conclusions: Pharmacist have the potential to contribute to a more effective care of patients suffering from hypertension or diabetes through patient counseling. Larger, longer and better controlled studies are however needed to confirm the results. Key words: Pharmacy services, telepharmacy, hypertension, diabetes

Introduction Rural Sweden Out of Sweden’s population of about 9.7 million, less than 300,000 inhabitants live in rural municipalities (1). These municipalities are 39 in total and are defined as having less than 7 inhabitants per square kilometer and less than 20,000 inhabitants in total. Most of these municipalities are located in the inland of the middle and northern parts of the country (2). The population in these areas are constantly decreasing at the same time as the average age is increasing. In the year 2030, it is estimated that the number of people that are able to work will be outnumbered by those that are not. Already today, in some municipalities, the number of people over 80 years old exceeds 10% of the inhabitants (1). When it comes to the social situation in the rural areas, there are few high income takers and the education level – especially among the men – is low. There is also a high proportion of people living under the social security norm. Both the men and women living in these parts of the country feel mentally well but physically unwell and their health is also worse with high incapacity rates compared to other parts of Sweden. The rural population has a low intake of vegetables, high alcohol consumption and a high proportion of obese people. This probably contributes to the shorter life expectancy and high mortality in myocardial infarction and diabetes seen in the rural areas (2). Myocardial infarction and hypertension There is, as mentioned above, a high mortality in myocardial infarction in rural Sweden (2). During a myocardial infarction, the heart does not receive enough oxygen which can lead to necrosis of the heart tissue and death. There are several factors that increase the risk of having a myocardial infarction. The ones that are effectible are: hypertension, smoking, diabetes, central obesity, stress, and a high ApoB/ApoA-1 ratio (dyslipidemia) (3). Hypertension is a major risk factor and the risk of dying from ischemic heart disease is decreased by half with every 20 mmHg reduction in systolic blood pressure (SBP) (4). Hypertension is also estimated to be the risk factor with most attributed deaths worldwide and the prevalence of hypertension increases with age. The blood pressure goal in Sweden is 140/90 mmHg and both medications and lifestyle changes can lower the blood pressure. Non-pharmacological interventions include lowering of stress, and decreased energy and salt intake, as well as a moderate alcohol consumption (5).

1

Diabetes mellitus As mentioned above, diabetes is an over-represented cause of death in rural parts of Sweden (2) and it is also a risk factor for myocardial infarction (3). Diabetes mellitus is a chronic disease that is defined by hyperglycemia. There are several different types of diabetes, the most common being type 1 and type 2. Under-treated diabetes mellitus leads to microvascular and neuropathic complications. The blood glucose value can be determined with an HbA1c blood test that measures the amount of irreversibly glycosylated hemoglobin that circulates in the blood. The HbA1c test tells you what the blood glucose was 2-3 month before the test (6). The American Diabetes Association (ADA) recommends that the HbA1c value should be below 7.0%. The recommendation in Sweden are that the HbA1c value should be less than 52 mmol/mol, which is equivalent to 6.0% (6). In addition to the pharmacological treatment of diabetes, the lifestyle of diabetes patients can affect the clinical outcome of the disease. Both weight loss, exercise, and smoking cessation can improve blood glucose values as well as reduce cardio vascular risk factors. A variety of diets have also been shown to improve blood glucose values for diabetics, e.g. Mediterranean diet and low-carbohydrate diets (7,8). Diabetes comorbidities

Diabetes mellitus patients have an increased risk of contracting other diseases. The most common comorbidities are obesity, hypertension, and dyslipidemia, but diabetics are also more prone to suffer from myocardial infarction (see above), depression, anxiety, and arthritis (9). The ADA recommendations for treatment of hypertension and dyslipidemia and prevention of heart failure are foremost lifestyle changes with reduced weight (if the patient is overweight or obese), increased exercise, a moderate intake of alcohol and reduced intake of sodium, saturated fat and cholesterol. If these actions are not enough, medications are prescribed to treat these conditions (10). Consultative pharmacy services Pharmacy services are services carried out by certified pharmacists. These not only involve preparation and dispensing of drugs, but also include consultative services to patients and institutions. Pharmacy services that include counseling of patients have been shown to be effective in improving disease states, e.g. lowering blood pressure and cholesterol. It has been estimated that interventions performed by pharmacists leads to a decrease in SBP of 8.4 mmHg while interventions by nurses only reduce it with 4.8 mmHg. Pharmacist interventions have also been demonstrated to increase the quality of 2

life and adherence (11). Since dispensing of medications has become more effective over the last decades, the community pharmacist with their pharmaceutical expertise could be used more effectively. This would be beneficial for patients and reduce the load on other health care professionals. The UK government for example, wants the community pharmacists to have a greater role when it comes to helping chronically ill patients managing their disease (12) Telepharmacy

The consultative pharmacy services can either take place face-to-face or the pharmacist can be working off-site. This later type of pharmacy service is called telepharmacy and the most common way of communication is via telephone or over the internet by videoconferencing (11,13). Telephone based contact with healthcare professionals have been shown to be an effective way of changing patient behaviors. Telepharmacy not only provide rural areas access to pharmacists but it can also be more convenient for the patients since the counseling is made at home – telepharmacy thus saves both travel costs and time (11). One prerequisite for telepharmacy to work optimally is, however, that the population has well-functioning telephone and internet networks. By learning how pharmacists better can be utilized in the primary care and at pharmacies – both face-to-face with the patients and off-site – the care of patients can potentially be improved with better life quality but also reduced costs for society. This study emanated from the health situation in rural Sweden and focuses on pharmacy services that provide counseling of patients with hypertension (a group that has an elevated risk of suffering from myocardial infarction) or diabetes. For the former patient group, telepharmacy services were analyzed since these might be of particular use when the distances to health services are long.

Objective The questions addressed in this literature study are: How can patient oriented consultative telepharmacy services in the primary care contribute to better outcomes for patients with hypertension? How can patient oriented consultative pharmacy services in the primary care or at pharmacies be used to improve the outcomes for diabetes patients?

3

Method This literature study was based on publications found between March 25 and April 30, 2015. PubMed was searched for articles with the search terms stated below (see Table 1). Publications that analyzed how pharmacists could improve the health status for people suffering from hypertension or diabetes through counseling were selected. The pharmacists needed to be directly in contact with the patient during the intervention. Case studies, studies with preliminary results, and review articles were excluded. In addition, the articles needed to be available via the University Library at Umeå University. Table 1. Search terms used in PubMed and selected publications. Date 150325

Search terms

Limitations Number

Selected

of items

references

English

59

(14)

(("Pharmacists"[Mesh]) AND

English

13

(15)

"Medication Therapy

Full text

Management"[Mesh]) AND

10 year 19

(16,17)

2

(18)

31

(19–23)

12

(24–26)

("Pharmacists"[Mesh]) AND "Rural Health Services"[Mesh]

150327

"Diabetes Mellitus"[Mesh] 150416

(("Diabetes Mellitus"[Mesh])

English

AND "Pharmacists"[Mesh])

Full text

AND "Disease

10 year

Management"[Mesh] 150416

(("Education, Pharmacy,

English

Continuing"[Mesh]) AND

Full text

"Diabetes Mellitus"[Mesh])

10 year

AND "Pharmacists"[Mesh] 150416

(("Patient Care Team"[Mesh])

English

AND "Diabetes

Full text

Mellitus"[Mesh]) AND

10 years

"Pharmacists"[Mesh] 150430 (("Telemedicine"[Mesh]) AND "Pharmacists"[Mesh]) AND

English Full text

"Cardiovascular Diseases"[Mesh]

4

Results Telepharmacy services for patients with hypertension Consultative telepharmacy services that aim at lowering the blood pressure of patients with hypertension have been tried in USA. Three studies were identified that analyzed such services (see Appendix A for summary). Two of the studies were telephone-based and one study included a web based pharmacy service. None of the studies were undertaken in rural areas. Blood pressure control

Green et al. (25) investigated if a web based pharmacy service could improve the treatment if hypertensive patients in a randomized controlled trial. The study was located to 10 medical centers in USA between 2005 and 2007. The patients that were included in the study had a SBP between 140-199 mmHg a diastolic blood pressure (DPB) between 90-190 mmHg and no other serious disease e.g. diabetes. The 730 participants all were given pamphlets describing the disease, importance of taking medication, and how the life-style effects the outcome. The participants were divided into 3 groups (see Figure 1): i) a control group received usual care (247 patients), ii) a group that received a home blood pressure monitor and training in using a web service that enables refilling of prescriptions, appointment booking, healthcare contact, and viewing of portions of one’s electronic medical record (EMR) (246 patients), iii) a group that received the same intervention as the previous but in addition also received pharmacist care management (237 patients). The participants in this last group first received a telephone call from a pharmacist who toke the participant’s medical history and set up an action plan including at least one life-style change that the patient was going to make (patient selected). After the telephone call, the pharmacist contacted the participants once every two weeks via the web service. During this contact, the participant provided the blood glucose readings, and medical concerns and progress of the life-style change was discussed. The pharmacist made recommendations (including medical adjustments) and changed the action plan if necessary. The web contact continued until the patient reached the blood pressure goal of